Auto Quote information page


Auto Insurance Quote Request


Why you need insurance
Please fill in the information below and we will contact you as soon as possible.
First Name: Last Name:
Street Address:
City: State: Zip Code:
Home Phone: Work Phone:
E-mail address:
Best time to contact (MT) me is:
How would you like us to contact you?


Driver Information

(All drivers in your household must be listed.)
Driver 1
Name:
Gender:
 Date of Birth:
Marital Status:
 Years Licensed:
Driver 2
Name:
Gender:
 Date of Birth:
Marital Status:
 Years Licensed:
Driver 3
Name:
Gender:
 Date of Birth:
Marital Status:
 Years Licensed:
Driver 4
Name:
Gender:
 Date of Birth:
Marital Status:
 Years Licensed:


Accident/Violation/Claim History (past 3 years)
Incident 1
Date: Driver: Description:
Incident 2
Date: Driver: Description:
Incident 3
Date: Driver: Description:
Incident 4
Date: Driver: Description:


Vehicle Information
Vehicle 1
Year:
Make:
Model:
Body Type:
VIN (Vehicle Identification Number): Usage:
Vehicle 2
Year:
Make:
Model:
Body Type:
VIN (Vehicle Identification Number): Usage:
Vehicle 3
Year:
Make:
Model:
Body Type:
VIN (Vehicle Identification Number): Usage:
Vehicle 4
Year:
Make:
Model:
Body Type:
VIN (Vehicle Identification Number): Usage:


]
Coverage Information
Bodily Injury:
Property Damage:
Uninsured Motorist Coverage:
Comprehensive Coverage:
Vehicle 1:
 Vehicle 2:
 Vehicle 3:
Vehicle 4:
Collision Coverage:
Vehicle 1:
 Vehicle 2:
 Vehicle 3:
Vehicle 4:
Other Coverages:


General Information
  • Your occupation:
  • Your Employer:
  • Total number of years employed:
    years
  • Current Insurance company:
  • How long have you been continuously insured?
    years
  • Policy Expiration Date:
  • Do you own your home?
    Yes No
  • How long have you lived at your current residence?
    years
  • Additional Comments:
W-B Insurance does NOT sell, lend, rent, exchange or give away customer information to third parties.The information you have provided will be used to prepare a quote for you and is subject to the company's review and approval.  This is NOT an insurance policy or binder!
 

This page was last updated on July 17, 2003 by R. Wright. Please report problems or errors to me at webmaster@wbins.com. While I make every attempt that information be complete and accurate, I cannot be liable for decisions based on these page contents.